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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIP 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: r Page of 1)/R K �- 0 a- D 41 Facility Address: City: Insption Dat S1 � v ' 0 z-- W. oE FA#: PR / Z / Program E m Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum ;�t 1320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product type. ff'Tank (2820) ❑ Containers (2821) ##of Containers: TA#: %�q`� (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: Total Capacity: �� 0 d gallons (per lank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TA#: 'Z (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: Total Capacity: /G U 6;" U gallons (per tank or cumulative for containers by product type) Install Date: EB-fank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: (j t- Ll Total Capacity: r&b gallons (per tank or cumulative for containers by product type) Install Date: 19-"'fank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) -a- 4 O ` 4 Product Type: Gr/A S %� Total Capacity: r-& 'o gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) / 5 ,. Product Type: ��v/,J/L �/ L� Total Capacity: 20 a gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: f z C?Ll gallons Total Capacity for Site: Z, Il gallons Comments: EHD Inspector: Reviewed Date: -0�/ Entered Date: By Initial: V*j Ki�L '0 By Initial: EHD 28-01 01/16/08